NCP Abdominal Aortic Aneurysm

Ulrich & Canale: Nursing Care Planning Guides: For Adults in Acute, Extended, and Home Care Settings, 6th Edition
Abdominal Aortic Aneurysm Repair
- Nursing Diagnoses/Collaborative Problems

An abdominal aortic aneurysm is an abnormal dilation of the wall of the abdominal aorta. The aneurysm usually develops in the segment of the vessel that is between the renal arteries and the iliac branches of the aorta. The most common cause of an abdominal aortic aneurysm is atherosclerosis. The plaque that forms on the wall of the artery causes degenerative changes in the medial layer of the vessel. These changes lead to loss of elasticity, weakening, and eventual dilation of the affected segment. Some other causes of abdominal aortic aneurysm include inflammation (arteritis), trauma, infection, congenital abnormalities of the vessel, and connective tissue disorders that cause vessel wall weakness.

Most abdominal aortic aneurysms are asymptomatic and are discovered during a routine physical examination (signs include palpation of a pulsatile mass in the abdomen and/or auscultation of a bruit over the abdominal aorta) or during a review of x-ray results of the abdomen or lower spine. The presence of symptoms such as mild to severe abdominal, lumbar, or flank pain and/or lower extremity arterial insufficiency is usually indicative of a large aneurysm that is exerting pressure on surrounding tissues or an aneurysm that is leaking.

Surgical repair of an aneurysm is usually performed if the aneurysm is growing rapidly and/or reaches a size of 5-6 cm or larger or if the client experiences symptoms. The procedure often involves the use of a synthetic graft, which is inserted to replace or support the weakened vessel.

This care plan focuses on the adult client hospitalized for surgical repair of an abdominal aortic aneurysm. Much of the postoperative information is applicable to clients receiving follow-up care in an extended care facility or home setting.

Abdominal Aortic Aneurysm Repair
- Description

1. Preoperative Fear/Anxiety
2. Potential complication: hypovolemic shock

1. Postoperative Risk for imbalanced fluid and electrolytes
1. third-spacing of fluid
2. excess fluid volume
3. deficient fluid volume
4. hypokalemia, hypochloremia, and metabolic alkalosis
2. Potential complications
1. hypovolemic shock
2. lower extremity arterial embolization
3. cardiac dysrhythmias
4. ischemic colitis
5. impaired renal function
3. Deficient knowledge, Ineffective therapeutic regimen management, or Ineffective health maintenance


NURSING DIAGNOSIS: Fear/Anxiety
related to:

1. unfamiliar environment and separation from significant others;
2. lack of understanding of diagnostic tests, surgical procedure, and postoperative care;
3. anticipated loss of control associated with effects of anesthesia;
4. risk of disease if blood transfusions are necessary;
5. anticipated postoperative discomfort and potential change in sexual functioning;
6. possibility of death.

Desired Outcome
The client will experience a reduction in fear and anxiety (see Standardized Preoperative Care Plan, Diagnosis 1 [pp. 97-98], for outcome criteria).
Nursing Actions and Selected Purposes/Rationales

1. Refer to Standardized Preoperative Care Plan, Diagnosis 1, for measures related to the assessment and reduction of fear and anxiety.
2. Implement additional measures to reduce fear and anxiety:
1. orient client to critical care unit if appropriate
2. describe and explain the rationale for equipment and tubes that may be present postoperatively (e.g., cardiac monitor, ventilator, intravenous and intra-arterial lines, nasogastric tube, urinary catheter)
3. explain that B/P may be taken in both arms and thighs in order to better evaluate circulatory status
4. reinforce physician's explanations and clarify misconceptions client has about effects of the surgery on sexual functioning (impotence can result from diminished blood flow in the mesenteric or internal iliac arteries during or after surgery and/or from nerve damage during surgery).


COLLABORATIVE DIAGNOSIS: Potential complication: hypovolemic shock

related to excessive blood loss if the aneurysm ruptures.
Desired Outcome
The client will not develop hypovolemic shock as evidenced by:

1. usual mental status
2. stable vital signs
3. skin warm and usual color
4. palpable peripheral pulses
5. urine output at least 30 ml/hour.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and immediately report signs and symptoms of conditions that indicate impending aneurysm rupture:
1. leaking aneurysm:
1. increasing abdominal girth
2. ecchymosis of flank area or perineum
3. frank or occult gastrointestinal bleeding (occurs if the aneurysm ruptures into the duodenum)
4. decreasing RBC, Hct, and Hgb levels
5. new or increased reports of lumbar, flank, abdominal, pelvic, or groin pain (accumulation of blood in the peritoneum and/or retroperitoneal spaces causes irritation of and pressure on the tissues and nerves)
6. diminishing or absent peripheral pulses
7. further decline in thigh B/P as compared with B/P in arm (thigh B/P is usually slightly lower than B/P in arm of a client with an abdominal aortic aneurysm)
2. expanding aneurysm:
1. new or increased reports of lumbar, flank, or groin pain (results from pressure on lumbar nerves)
2. increased size of pulsating mass in abdomen
3. increasing sense of abdominal and/or gastric fullness (results from pressure on duodenum)
4. decreasing motor or sensory function of lower extremities (results from pressure on lumbar and/or sacral nerves).
2. Assess for and report signs and symptoms of hypovolemic shock:
1. restlessness, agitation, confusion, or other change in mental status
2. significant decrease in B/P
3. postural hypotension
4. rapid, weak pulse
5. rapid respirations
6. cool skin
7. pallor, cyanosis
8. diminished or absent peripheral pulses
9. urine output less than 30 ml/hour.
3. Implement measures to decrease risk of aneurysm rupture:
1. instruct client to avoid elevating legs when in bed, using knee gatch, and crossing legs in order to prevent restriction of blood flow to the lower extremities and subsequent increase in vascular pressure at the aneurysm site
2. perform actions to prevent an increase in blood pressure:
1. limit client's activity as ordered
2. instruct client to avoid activities that create a Valsalva response (e.g., straining to have a bowel movement, holding breath while moving up in bed, lifting heavy objects)
3. implement measures to reduce fear and anxiety (see Preoperative Diagnosis 1)
3. administer antihypertensives if ordered to reduce pressure in the dilated vessel.
4. If signs and symptoms of hypovolemic shock occur:
1. place client flat in bed unless contraindicated
2. monitor vital signs frequently
3. administer oxygen as ordered
4. administer blood and/or volume expanders as ordered (these need to be used with caution since increased vascular pressure can extend a tear at site of rupture)
5. prepare client for insertion of hemodynamic monitoring devices (e.g., central venous catheter, intra-arterial catheter) if indicated
6. prepare client for emergency surgical repair of aneurysm if indicated.


NURSING DIAGNOSIS: Risk for imbalanced fluid and electrolytes

1. third-spacing of fluid related to:
1. increased capillary permeability in surgical area associated with the inflammation that occurs following extensive dissection of tissue during major abdominal surgery
2. increased vascular hydrostatic pressure associated with excess fluid volume if present
3. hypoalbuminemia associated with the escape of proteins from the vascular space into the peritoneum (a result of increased capillary permeability in the surgical area);
2. excess fluid volume related to:
1. vigorous fluid replacement
2. fluid retention associated with:
1. increased secretion of antidiuretic hormone (output of ADH is stimulated by trauma, pain, and anesthetic agents)
2. renal insufficiency (can occur if there is inadequate blood flow to the kidneys during or after surgery)
3. reabsorption of third-space fluid (occurs about the 3rd postoperative day);
3. deficient fluid volume related to restricted oral fluid intake before, during, and after surgery; blood loss; and loss of fluid associated with nasogastric tube drainage;
4. hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and hydrochloric acid associated with nasogastric tube drainage.

Desired Outcome
The client will experience resolution of third-spacing as evidenced by:

1. absence of ascites
2. B/P and pulse within normal range for client and stable with position change.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of third-spacing:
1. ascites (e.g., increase in abdominal girth, dull percussion note over abdomen with finding of shifting dullness)
2. evidence of vascular depletion (e.g., postural hypotension; weak, rapid pulse).
2. Monitor serum albumin levels. Report below-normal levels (low serum albumin levels result in fluid shifting out of vascular space because albumin normally maintains plasma colloid osmotic pressure).
3. Implement measures to prevent further third-spacing and/or promote mobilization of fluid back into the vascular space:
1. perform actions to reduce excess fluid volume (see Standardized Postoperative Care Plan, Diagnosis 4, action b.2 [p. 107])
2. administer albumin infusions if ordered to increase colloid osmotic pressure.
4. Consult physician if signs and symptoms of third-spacing worsen or fail to resolve within expected length of time (reabsorption usually begins on 3rd postoperative day).

Desired Outcome
The client will not experience excess fluid volume (see Standardized Postoperative Care Plan, Diagnosis 4, outcome b [p. 107], for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
Refer to Standardized Postoperative Care Plan, Diagnosis 4, action b, for measures related to assessment, prevention, and treatment of excess fluid volume.
Desired Outcome
The client will not experience deficient fluid volume, hypokalemia, hypochloremia, or metabolic alkalosis (see Standardized Postoperative Care Plan, Diagnosis 4, outcome a [p. 106], for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
Refer to Standardized Postoperative Care Plan, Diagnosis 4, action a, for measures related to assessment, prevention, and treatment of deficient fluid volume, hypokalemia, hypochloremia, and metabolic alkalosis.


COLLABORATIVE DIAGNOSIS: Potential complications

1. hypovolemic shock related to hypovolemia associated with blood loss during surgery, third-space fluid shift, and hemorrhage (can occur as a result of inadequate wound closure and/or stress on and subsequent leakage or rupture of anastomosis sites);
2. lower extremity arterial embolization related to dislodgment of necrotic debris or clot from surgical site;
3. cardiac dysrhythmias related to altered nodal function and myocardial conductivity associated with:
1. myocardial hypoxia resulting from:
1. altered respiratory function
2. diminished myocardial blood flow that can result from pre-existing coronary artery disease, hypotension (can occur as a result of hypovolemia, vasodilation associated with rapid warming, and effects of some medications), and sympathetic nervous system-mediated vasoconstriction that results from pain, stress, and hypothermia
2. myocardial damage if a perioperative myocardial infarction has occurred
3. hypokalemia if present;
4. ischemic colitis related to diminished blood supply to the colon associated with ligation of the inferior mesenteric artery during surgery, hypovolemia, and/or embolization;
5. impaired renal function related to insufficient blood flow to the kidneys associated with hypovolemia and prolonged aortic clamp time.

Desired Outcome
The client will not develop hypovolemic shock (see Preoperative Diagnosis 2, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of leakage at anastomosis sites:
1. new or expanding hematoma at incision site and/or ecchymosis of flank or perineal area
2. increased abdominal girth (can also occur with third-spacing)
3. new or increased reports of lumbar, flank, abdominal, pelvic, or groin pain
4. increasing feeling of abdominal and/or gastric fullness unrelated to oral intake
5. diminishing or absent peripheral pulses
6. decreased motor or sensory function in lower extremities
7. decreasing B/P, increasing pulse
8. decreasing RBC, Hct, and Hgb values.
2. Assess for and report signs and symptoms of hypovolemic shock (see Preoperative Diagnosis 2, action b).
3. Implement measures to prevent hypovolemic shock:
1. perform actions to prevent or treat hypovolemia:
1. implement measures to prevent further third-spacing and/or promote mobilization of fluid back into vascular space (see Postoperative Diagnosis 1, action a.3)
2. provide maximum fluid intake allowed (a fluid restriction may be ordered to prevent fluid overload and subsequent pressure on the anastomosis sites)
3. administer blood and/or volume expanders as ordered
2. perform actions to reduce stress on and subsequent separation of anastomosis sites:
1. instruct client to avoid positions that compromise peripheral blood flow (e.g., elevating legs when in bed, use of knee gatch, crossing legs)
2. implement measures to reduce the accumulation of gas and fluid in the gastrointestinal tract and prevent nausea and vomiting (see Standardized Postoperative Care Plan, Diagnoses 7, action b and 8, action b [pp. 110-111])
3. implement measures to prevent or treat excess fluid volume (see Standardized Postoperative Care Plan, Diagnosis 4, action b.2 [p. 107])
4. instruct client to avoid activities that create a Valsalva response (e.g., straining to have a bowel movement, holding breath while moving up in bed)
5. instruct client to avoid vigorous coughing; consult physician about an order for an antitussive if indicated
6. administer antihypertensives if ordered to reduce blood pressure.
4. If signs and symptoms of hypovolemic shock occur:
1. place client flat in bed unless contraindicated
2. monitor vital signs frequently
3. administer oxygen as ordered
4. administer blood products and/or volume expanders if ordered (these need to be used with caution if anastomosis site separation is suspected)
5. prepare client for surgery if indicated.

Desired Outcome
The client will not experience lower extremity arterial embolization as evidenced by:

1. no reports of pain or diminished sensation in lower extremities
2. palpable peripheral pulses
3. usual temperature and color of extremities.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of lower extremity arterial embolization:
1. reports of pain (onset is often sudden and severe) and/or numbness in lower extremity(ies)
2. diminishing or absent peripheral pulses (pulses may be absent for a few hours after surgery as a result of vasospasm)
3. cool, pale, or mottled extremities.
2. Implement measures to reduce risk of embolization:
1. limit client's activity as ordered
2. instruct client to avoid activities that create a Valsalva response (e.g., straining to have a bowel movement, holding breath while moving up in bed) in order to prevent dislodgment of existing thrombi.
3. If signs and symptoms of lower extremity arterial embolization occur:
1. maintain client on bed rest
2. prepare client for the following if planned:
1. diagnostic studies (e.g., Doppler ultrasound, arteriography)
2. embolectomy.

Desired Outcome
The client will maintain normal sinus rhythm as evidenced by:

1. regular apical pulse at 60-100 beats/minute
2. equal apical and radial pulse rates
3. absence of syncope and palpitations
4. ECG reading showing normal sinus rhythm.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of cardiac dysrhythmias (e.g., irregular apical pulse; pulse rate below 60 or above 100 beats/minute; apical-radial pulse deficit; syncope; palpitations; abnormal rate, rhythm, or configurations on ECG).
2. Implement measures to prevent cardiac dysrhythmias:
1. perform actions to maintain an adequate respiratory status (see Standardized Postoperative Care Plan, Diagnoses 2, action b and 3, action b [pp. 104-105]) in order to maintain adequate myocardial tissue oxygenation
2. perform actions to decrease stimulation of the sympathetic nervous system (sympathetic stimulation increases the heart rate and causes vasoconstriction, both of which increase cardiac workload and decrease oxygen availability to the myocardium):
1. implement measures to reduce pain and anxiety (see Standardized Postoperative Care Plan, Diagnoses 6, action d and 21, action b [pp. 109 and 124])
2. implement measures to keep client from getting cold (e.g., maintain a comfortable room temperature, provide adequate clothing and blankets)
3. perform actions to prevent or treat hypokalemia (see Standardized Postoperative Care Plan, Diagnosis 4, action a.2 [p. 106])
4. perform actions to prevent or treat hypotension:
1. consult physician before giving negative inotropic agents, diuretics, and vasodilating agents if systolic B/P is below 90-100 mm Hg
2. perform actions to prevent hypovolemic shock (see action a.3 in this diagnosis) in order to maintain an adequate vascular volume
3. administer narcotic (opioid) analgesics judiciously, being alert to the synergistic effect of the narcotic ordered and the anesthetic that was used during surgery
4. gradually bring client's body temperature to normal if hypothermic (rapid warming results in vasodilation)
5. administer sympathomimetics (e.g., dopamine) if ordered.
3. If cardiac dysrhythmias occur:
1. administer antidysrhythmics as ordered
2. restrict client's activity based on his/her tolerance and severity of the dysrhythmia
3. maintain oxygen therapy as ordered
4. assess cardiovascular status frequently and report signs and symptoms of inadequate tissue perfusion (e.g., decrease in B/P, cool skin, cyanosis, diminished peripheral pulses, urine output less than 30 ml/hour, restlessness and agitation, shortness of breath)
5. have emergency cart readily available for cardioversion, defibrillation, or cardiopulmonary resuscitation.

Desired Outcome
The client will not develop ischemic colitis as evidenced by:

1. absence of blood in stools
2. absence of diarrhea
3. absence of or decrease in abdominal pain
4. soft, nontender abdomen.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of ischemic colitis (e.g., blood in stools, diarrhea, reports of new or increasing abdominal pain, distended abdomen).
2. Implement measures to prevent hypovolemic shock and embolization (see actions a.3 and b.2 in this diagnosis) in order to maintain adequate blood supply to the colon.
3. If signs and symptoms of ischemic colitis occur:
1. administer antimicrobials if ordered
2. prepare client for the following if planned:
1. colonoscopy
2. colon resection (usually performed if client has extensive tissue necrosis or gangrenous patches have developed)
3. embolectomy.

Desired Outcome
The client will maintain adequate renal function as evidenced by:

1. urine output at least 30 ml/hour
2. BUN, serum creatinine, and creatinine clearance within normal range.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of impaired renal function (e.g., urine output less than 30 ml/hour, urine specific gravity fixed at or less than 1.010, elevated BUN and serum creatinine levels, decreased creatinine clearance).
2. Implement measures to prevent hypovolemic shock (see action a.3 in this diagnosis) in order to maintain adequate renal blood flow.
3. If signs and symptoms of impaired renal function occur, assess for and report signs of acute renal failure (e.g., oliguria or anuria; weight gain; edema; elevated B/P; lethargy and confusion; increasing BUN and serum creatinine, phosphorus, and potassium levels).


NURSING DIAGNOSIS: Deficient knowledge, Ineffective therapeutic regimen management, or Ineffective health maintenance*

*The nurse should select the diagnostic label that is most appropriate for the client's discharge teaching needs.
Desired Outcome
The client will identify ways to prevent or slow the progression of atherosclerosis.
Nursing Actions and Selected Purposes/Rationales

1. Inform the client that certain modifiable factors such as elevated serum lipids, a sedentary lifestyle, smoking, and hypertension have been shown to increase the risk of atherosclerosis.
2. Assist client to identify changes in lifestyle that could reduce the risk for atherosclerosis (e.g., dietary modifications, smoking cessation, physical exercise on a regular basis).
3. Provide instructions on ways the client can reduce intake of saturated fat and cholesterol:
1. reduce intake of meat fat (e.g., trim visible fat off meat; replace fatty meats such as fatty cuts of steak, hamburger, and processed meats with leaner products)
2. reduce intake of milk fat (avoid dairy products containing more than 1% fat)
3. reduce intake of trans fats (e.g., avoid stick margarine and shortening and foods such as commercial baked goods that are prepared with these products)
4. use vegetable oil rather than coconut or palm oil in cooking and food preparation
5. use cooking methods such as steaming, baking, broiling, poaching, microwaving, and grilling rather than frying
6. restrict intake of eggs (recommendations about the number of whole eggs allowed per week vary depending on the client's lipid levels).
4. Instruct client to take lipid-lowering agents (e.g., HMG-CoA reductase inhibitors ["statins"], ezetimibe, gemfibrozil, niacin) as prescribed.

Desired Outcome
The client will state signs and symptoms to report to the health care provider.
Nursing Actions and Selected Purposes/Rationales

1. Refer to Standardized Postoperative Care Plan, Diagnosis 22, action c, for signs and symptoms to report to the health care provider.
2. Instruct client to report these additional signs and symptoms:
1. sudden or gradual increase in lower back, flank, groin, or abdominal pain
2. chest pain
3. coolness, pallor, or blueness of lower extremities
4. increased weakness and fatigue
5. decreased urine output
6. bloody or persistent diarrhea
7. increased bruising of incision site, flank area, or perineum
8. impotence.

Desired Outcome
The client will verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider, medications prescribed, activity level, and wound care.
Nursing Actions and Selected Purposes/Rationales

1. Refer to Standardized Postoperative Care Plan, Diagnosis 22, for routine postoperative instructions and measures to improve client compliance.
2. Reinforce the physician's instructions regarding:
1. importance of scheduling adequate rest periods
2. ways to prevent constipation and subsequent straining to have a bowel movement (e.g., drink at least 10 glasses of liquid/day unless contraindicated, increase intake of foods high in fiber, take stool softeners if necessary)
3. the need to avoid sexual intercourse, isometric exercise/activity (e.g., lifting objects over 10 pounds, pushing heavy objects), and strenuous exercise for specified length of time (usually 4-12 weeks depending on the activity)
4. the need to take prophylactic antimicrobials prior to any dental work or invasive procedure (some physicians recommend this for the first 6-12 months following surgical placement of a synthetic graft).